Behavioral Health RN Case Manager, RN

Position Location: 100% remote

About the Role

The Behavioral Health RN Case Manager delivers case management services to individuals covered by group health plans administered by Imagine360. This role serves patients with medical, behavioral health, mental health, and/or neurodevelopmental disorder needs, adhering to department criteria. The RN collaborates with physicians, providers, members, and other stakeholders to assess, plan, coordinate, monitor, evaluate, and advocate for necessary options and services to address comprehensive health needs. They leverage communication and resources to enhance quality and cost-effective outcomes, acting as a liaison to providers, physicians, and members. The RN receives member referrals from non-Behavioral Health Case Managers and Disease Management clinicians to support the behavioral health needs of those members.

Responsibilities

• Identify, collect, process, and manage data to perform the Case Management process using Imagine360-approved clinical guidelines and following Medical Management Policy and Procedures.
• Conduct comprehensive clinical assessments according to established policies and procedures to identify and provide appropriate care and coordination for behavioral health, mental health, and neurodevelopmental disorder diagnoses.
• Manage members with behavioral health, mental health, neurodevelopmental disorder diagnoses, and those with medical diagnoses that also have behavioral health needs.
• Utilize clinical knowledge, expertise, and educational resources to provide verbal and/or written educational materials to members regarding diagnosis, procedures, and/or treatment.
• Assess the need for and collaborate with community resources for members in case management.
• Use assigned software accurately to document and complete all steps of review of medical necessity and case management processes, including time slips.
• Facilitate Patient Satisfaction Surveys.
• Assess for cost savings and document them in the assigned software platform.
• Appropriately escalate complex cases to Supervisor, IDCT, or designee as needed.
• Perform essential activities of case management while maintaining members' confidentiality, safety, advocacy, adherence to ethical, legal, accreditation, and regulatory standards.
• Perform assessments of each member to identify Case Management needs.
• Consistently exercise discretion and judgment to analyze, interpret, make deductions, and decide necessary actions based on varying facts and circumstances of each case.
• Determine measurable goals utilizing motivational interviewing and behavior change models, and coach clients while monitoring self-care practices.
• Utilize industry-standard tools to guide individuals with chronic/ongoing health conditions through coaching, assessments, listening, and other techniques.
• Execute activities or interventions to achieve the goals in the plan.
• Organize, integrate, and modify the resources needed to reach the goals in the plan.
• Monitor all information from relevant sources in the plan and its activities/services to determine effectiveness.
• Evaluate at repeated intervals to determine the ultimate effectiveness of the plan and modify it appropriately to meet goals.
• Research medical procedures, treatments, and coding when necessary.
• Measure the outcomes of interventions.
• Adhere to care management core components throughout the continuum of care:
  • Case Management Concepts
  • Case Management Principles and Strategies
  • Psychosocial and Support Systems
  • Healthcare Management and Delivery
  • Healthcare Reimbursement
  • Vocational Concepts and Strategies
• Act as a role model in demonstrating core values in customer service delivery.
• Provide timely and thorough follow-up with internal and external customers.
• Appropriately escalate difficult issues up the chain of command.
• Serve on committees, work groups, and/or process improvement teams to assist in improving quality/customer satisfaction.
• Recognize and alert appropriate supervisors of trends within their scope of responsibility that fall outside of quality parameters.
• Perform self-quality monitoring to develop and execute plans to meet established goals.
• Provide ongoing feedback to help optimize quality performance.
• Collaborate with others cross-departmentally to improve or streamline procedures.
• Develop new or improve current internal processes to enhance quality.
• Attend and participate in team meetings, trainings, and other job-specific events as required.
• Communicate (in compliance with HIPAA) with brokers, vendors, Relationship Managers, HR representatives, and stop loss as needed.
• Adhere to established internal regulations regarding Department of Labor, HIPAA, ERISA, and department/company policies and procedures.
• Participate in the Quality Management Program via collecting and adhering to performance metrics.
• Complete HIPAA Training annually.
• Perform all tasks in accordance with HIPAA/PHI guidelines.
• Complete duties in accordance with the scope of licensure and certifications held or requested.
• Perform other duties and projects as assigned.

Scope of Practice

• Evaluating clinical data and assessing its appropriateness for treatment based on Imagine360 clinical guidelines.
• Coordination of treatment plans, interventions, and outcome measurements.
• Provide rationale for the effects of medication and treatments.
• Provide patient education and educational resources.
• Accurately report:
  • Administration of medication and treatments
  • Client response
  • Contact with other healthcare team members
• Respect the client's right to privacy by protecting confidential information.
• Promote and participate in education and counseling based on health needs.
• Clarify any treatment believed to be inaccurate, non-efficacious, or contraindicated by consulting with the appropriate practitioner.
• Knowledge and practice of the core components of Case Management:
  • Case Management Concepts
  • Principles of Practice
  • Healthcare Management & Delivery
  • Healthcare Reimbursement
  • Psychosocial Aspects of Care
  • Rehabilitation
  • Professional Development & Advancement
  • Quality and Outcomes Evaluation and Measurement
  • Ethical, Legal, and Practice Standards

Requirements

• Nursing degree from an accredited college, university, or nursing school. Bachelor's degree in nursing preferred but not required.
• 3+ years' experience working with Behavioral/Mental Health patients or programs.
• 1+ years in Case Management, discharge planning, or managed care experience, or transferable nursing experience and skills.
• Experience with Utilization Management and standardized criteria.
• Experience working in a URAC-accredited Case Management program.
• Experience working within an insurance agency or TPA specializing in employee benefits and self-funded medical plans.

Skills and Abilities

• Ability to work independently in a home office environment.
• Proficiency in Microsoft Outlook, Word, Excel, and PowerPoint, and navigation using the internet.
• Ability to resolve problems independently and demonstrate multi-tasking skills.
• Strong written, oral, and telephonic communication skills.
• Strong presentation skills.
• Commitment to building new skills and fostering a positive work environment.
• Demonstrated organizational skills, problem-solving, analytical skills, and attention to detail.
• Ability to prioritize workloads, multi-task, and manage priorities to meet deadlines.
• Ability to maintain the confidentiality of protected health information in compliance with HIPAA regulations.

Qualifications

• Current, active, and unrestricted compact Registered Nurse license. Must maintain CEUs as required by the State Board of Nursing.
• Must be willing to obtain and maintain additional license(s) as required to perform job functions.
• Current Certified Case Manager (CCM) Certificate preferred; if not current, must pursue and achieve CCM Certification within three years of employment.

Benefits

• Multiple health plan options.
• Company-paid employee premiums for disability and life insurance.
• Parental Leave Policy.
• 20 days PTO to start / 10 Paid Holidays.
• Tuition reimbursement.
• 401k Company contribution.
• Company-paid Short & Long-term Disability plus Life Insurance.
• Professional development initiatives / continuous learning opportunities.
• Opportunities to participate in and support the company's diversity and inclusion initiatives.